PMP Survey

We would like your feedback! As an enrolled patient in our Patient Management Program, your satisfaction is very important to us. Please take a moment to tell us how we are doing by choosing the response that most closely matches your experience with our program.

{# pageNumbers}
Patient Name (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
City and State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{# pageNumbers}
Untitled {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Fort MyersDaytona BeachSt. PetersburgOrlando (Bliss Rx)Tallahassee
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{# pageNumbers}
Please choose the most appropriate response based on your satisfaction to the following question {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Less than 1 yearMore than 1 yearNot sure
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{# pageNumbers}
Please choose the most appropriate response that applies to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Less than 1 dayLess than 2 daysLess than 3 daysMore than 5 days
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{# pageNumbers}
Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Extremely DissatisfiedVery DissatisfiedDissatisfiedSomewhat SatisfiedSatisfiedVery SatisfiedExtremely Satisfied
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{# pageNumbers}
Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Extremely DissatisfiedVery DissatisfiedSomewhat disatisfiedSlightly DissatisfiedNot at all DissatisfiedNot Applicable
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{# pageNumbers}
Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Extremely DissatisfiedVery DissatisfiedDissatisfiedSomewhat SatisfiedSatisfiedVery SatisfiedExtremely Satisfied
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{# pageNumbers}
Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
Extremely DissatisfiedDissatisfiedSatisfiedExtremely Satisfied
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{{ $context.parentContext.dataItem.get_label() }}
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{# pageNumbers}
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{# pageNumbers}

PMP Survey

PMP Survey

We would like your feedback! As an enrolled patient in our Patient Management Program, your satisfaction is very important to us. Please take a moment to tell us how we are doing by choosing the response that most closely matches your experience with our program.

Patient Name (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
City and State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Untitled {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Please choose the most appropriate response based on your satisfaction to the following question {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Please choose the most appropriate response that applies to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
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{{ $dataItem.get_label() }}
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{ binding firstError.message }
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Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
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Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
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Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
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Please choose the most appropriate response based on your satisfaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
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Please use the space below to give any other feedback about the Patient Management Program (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }